Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including asthma, toe amputation, and depression was observed to have a Primatene mist inhaler, calcium carbonate tablets, and triamcinolone cream on the over-bed table in full view. The resident reported that nursing staff were not aware of the inhaler and that these medications had been at the bedside for some time. The resident was cognitively intact but required assistance with activities of daily living. Review of the medical record revealed no assessment for the ability to self-administer medications, no physician's order for self-administration, and no care plan addressing self-administration of medications. Additionally, there were no physician's orders for the inhaler or calcium carbonate. Multiple staff interviews confirmed that residents should not have medications at the bedside without an assessment and physician's order. The DON acknowledged that the resident had not been assessed for self-administration of medications. Nursing and CNA staff stated that medications should not be left at the bedside and would have removed them if noticed. Facility policy requires an interdisciplinary team assessment and documentation in the medical record and care plan before allowing self-administration, which was not followed in this case.